Determining the presence or absence of middle ear disorders: an evidence-based systematic review on the diagnostic accuracy of selected assessment instruments

Wideband frequency impedance for diagnosis of ossicular chain abnormality

BACKGROUND

The accurate estimation of the ossicular chain abnormalities using existing functional examinations has been difficult.

AIMS/OBJECTIVES

This study aimed to verify the accuracy of preoperative diagnosis of ossicular chain abnormalities using a wideband frequency impedance (WFI) meter, which can measure the dynamic characteristics of the middle ear.

MATERIAL AND METHODS

Retrospective cohort study. Fourteen ears of patients with ossicular chain abnormalities that were definitively diagnosed surgically were included in this study. The following data were collected for each participant: sound pressure level (SPL) curve measured using the WFI meter and a sweep frequency impedance (SFI) meter, WFI measurements plotted on the resonance frequency (RF)-ΔSPL plane, distribution map of the dynamic characteristics of the middle ear, preoperative audiometry results, and the definitive surgical diagnosis.

RESULTS

The SPL curve obtained using the WFI meter had lesser noise than that obtained using the SFI meter. The distribution map revealed that the ossicular chain separation range and ossicular chain fixation range were completely separated. The hearing data tended to be poor in cases with small ΔSPL.

CONCLUSIONS AND SIGNIFICANCE

WFI can potentially enhance the accuracy of SFI. In addition, it can also be used for the classification of ossicular chain separation and fixation as well as the quantification of fixation in cases of ossicular chain anomalies that cannot be diagnosed using conventional tests.

Implementation of Wideband Acoustic Immittance in Clinical Practice: Relationships among Audiologic and Otologic Findings

A number of studies have produced normative and developmental data and examples of wideband acoustic immittance (WAI) obtained in ears with pathologies and or dysfunction. However, incorporation of this tool into clinical audiology and otolaryngology practice has been slower than expected, potentially due to challenges with interpretation, integration into existing test batteries, and confidence in practical application. This article presents information aimed at helping clinicians increase their confidence in using this new tool by becoming more familiar and making connections with the ways that WAI outcomes both align with and add to standard immittance, audiometric and otologic diagnostic test outcomes. This article presents several case studies to demonstrate the use of WAI in realistic clinical settings. Each case presents a brief background, case history, audiologic/otologic findings, and initial recommendations, followed by a discussion on how the inclusion of WAI test outcomes aids in diagnostic decisions. The overall aim of this work is to identify the relationships among different diagnostic test outcomes, to demonstrate basic WAI interpretation principles, and encourage the reader to engage with this diagnostic tool in clinical practice.

Effects of earlens lens placement on sound field thresholds, tympanometric measurements and wideband acoustic immittance

OBJECTIVE

The Earlens is a direct-drive hearing device consisting of a lens which physically displaces the umbo to achieve appropriate gain. The objective is to determine the clinical acceptability of clinical immittance measurements in Earlens wearers.

DESIGN

Controlled before-after within-subjects repeated measures study.

STUDY SAMPLE

Data is reported for measurements obtained on 15 subjects (average age of 72.2 years) with data from 30 ears.

RESULTS

There was a small effect of lens placement on sound field thresholds in most subjects. The largest damping effect of 4 dB was observed at 1000 Hz. An average reduction of 0.17 mL was identified in compliance following lens placement (p < 0.05). An effect of the lens on power absorbance obtained at ambient and peak pressure was found. The lens resulted in an increase in power absorbance at low frequencies (below 500 Hz) and a decrease in the mid to high-frequency range of approximately 500-3500 Hz (p < 0.05).

CONCLUSIONS

Lens wear had a small effect on audiometric thresholds and tympanometry for most patients. Clinicians who use compliance and power absorbance should take into consideration lens effects on these measurements. Additional work is required to develop clinical normative ranges of these measures for wearers of the Earlens.

Assessment of Pediatric Middle Ear Effusions With Wideband Tympanometry

OBJECTIVE

To determine if wideband tympanometry (WBT) can differentiate types of middle ear effusion (MEE): serous, mucoid, and purulent.

STUDY DESIGN

Prospective cohort study.

SETTING

Tertiary care children's hospital.

METHODS

Children who met American Academy of Otolaryngology-Head and Neck Surgery's guidelines for ventilation tube insertion had WBT after anesthesia induction but before tympanotomy. MEE was categorized into 1 of 4 comparison groups: serous effusion, mucoid effusion, purulent effusion, or no effusion. WBT measurements were averaged to 16 one-third octave frequency bands, and comparison of the absorbance patterns for each MEE type was performed through a linear mixed effects model.

RESULTS

A total of 118 children (211 ears) were included: 47 females (39.8%) and 71 males (60.2%). The mean age was 2.73 years (95% CI, 2.25-3.22); mean weight, 14.35 kg (95% CI, 12.85-15.85); and mean Z score, 1.13 (95% CI, -0.64 to 2.33). Effusions included 61 mucoid (28.9%), 30 purulent (14.2%), and 14 serous (6.6%), with 106 (50.2%) having no effusion. No significant differences were found for sex, race, age, weight, or Z score among the 4 types of effusion (P < .05). WBT showed a significant difference in median absorption among the effusion groups (P < .001), with a medium effect size of 0.35.

CONCLUSIONS

WBT has potential use to differentiate types of MEE and should be studied further as a tool for investigating how the natural history and management of serous and mucoid effusions may differ.

Indications for Eustachian tube dilation

PURPOSE OF REVIEW

Eustachian tube dilation is a controversial surgical procedure because the intended problem for which it is meant to address, obstructive Eustachian tube dysfunction, is a clinical diagnosis without a reliable diagnostic tool to test.In the past 10 years, balloon dilation Eustachian tuboplasty (BDET) has been the most commonly performed Eustachian tube dilation procedure. The present review seeks to identify the patients who may benefit from this procedure and thus propose the indications.

RECENT FINDINGS

Two randomized controlled trials for BDET published in the past 2 years showed statistically significant improvement in terms of symptomatic relief based on the ETDQ-7 scores and conversion of abnormal tympanograms (type B and type C) to normal tympanograms (type A).

SUMMARY

Based on the review of the evidence available so far, the proposed indication for Eustachian tube dilation using BDET is for a patient with ALL of the following: aural fullness greater than 12 weeks; type B or C tympanogram; ETDQ-7 mean score more than 2; and failed medical management including Valsalva maneuver and either 4 weeks of nasal steroids or 1 week of oral steroids.

Wideband tympanometry and absorbance measurements in otosclerotic ears

OBJECTIVES

This study aimed to assess absorbance using a thorough analysis of individual points of its plot in ears with intraoperatively confirmed otosclerosis. To the best of our knowledge, until recently no analyses have been performed that concerned the shape of an absorbance plot and a detailed analysis of its individual points. This study is the first to undertake such an issue.

METHODS

A total of 77 otosclerotic ears were included in the study. Pure tone audiometry, low frequency tympanometry, and wide band tympanometry including absorbance were performed preoperatively. The average patients' age in the group was 43.49 years (standard deviation = 10.44). Individual points of absorbance plot were thoroughly analyzed. Parameters were analyzed, such as resonance frequency; number of peaks; maximum absorbance (Height); and plot Width at the following Heights: 1/3, 1/2, and 2/3 (Width1/3, Width1/2, Width2/3, respectively), as well as associated absorbance parameters and frequencies.

RESULTS

Data analysis revealed five different types of absorbance plots. Numerous statistically significant differences regarding the parameters of individual points of the plots were found among the distinguished types.

CONCLUSIONS

There are five types of absorbance plots in otosclerotic ears: type I, characterized by two distinct peaks, closely resembling normal ear absorbance plot; type II with a single distinct peak reaching high values of absorbance; type III with reduced absorbance for frequencies <2000 Hz; type IV with reduced absorbance for all frequencies; and type V with reduced absorbance for frequencies >2000 Hz. Absorbance measurements may play an important role in the diagnostics of otosclerosis; however, further research is necessary in this area.

LEVELS OF EVIDENCE

4 Laryngoscope, 129:E365-E376, 2019.

Emerging Technologies for the Diagnosis of Otitis Media

OBJECTIVE

To review new experimental techniques for the diagnosis of otitis media (OM).

DATA SOURCES

Literature search in English in the following databases: MEDLINE (via PubMed), Ovid Medline, Google Scholar, and Clinical Evidence (BMJ Publishing) between January 1, 2005, and April 30, 2018. Subsequently, articles were reviewed and included only if relevant.

REVIEW METHODS

MeSH terms: ["diagnosis"] AND [all forms of OM] AND ["human"] AND ["ear"] and ["tympanic membrane"]. The retrieved innovative diagnostic techniques rely on and take advantage of the physical properties of the tympanomastoid cavity components: tympanic membrane (TM) thickness, its translucency and compliance; middle ear fluid characteristics; biofilm presence; increased tissue metabolic activity in OM states; and fluid presence in the mastoid cavity. These parameters are taken into account to establish OM diagnosis objectively. We review spectral gradient acoustic reflectometry, digital otoscopy, TM image analysis, multicolor reflectance imaging, anticonfocal middle ear assessment, optical coherence tomography, quantitative pneumatic otoscopy, transmastoid ultrasound, wideband measurements, TM thickness mapping, shortwave infrared imaging, and wideband acoustic transfer functions.

CONCLUSIONS

New experimental techniques are gradually introduced to overcome the limitations of standard otoscopy. The aforementioned techniques are still under investigation and are pending widespread clinical use. The implementation of these techniques in the market is dependent on their success in clinical trials, as well as on their future cost.

IMPLICATION FOR PRACTICE

New techniques for the diagnosis of OM can objectively evaluate the morphology of the TM, determine the presence of middle ear fluid and evaluate its content, and thus potentially replace standard otoscopy.

Factors affecting sound energy absorbance in acute otitis media model of chinchilla

Acute otitis media (AOM) is a rapid-onset infection of the middle ear which results in middle ear pressure (MEP), middle ear effusion (MEE), and structural changes in middle ear tissues. Previous studies from our laboratory have identified that MEP, MEE, and middle ear structural changes are three factors affecting tympanic membrane (TM) mobility and hearing levels (Guan et al., 2014, 2013). Sound energy reflectance or absorbance (EA) is a diagnostic tool increasingly used in clinical settings for the identification of middle ear diseases. However, it is unclear whether EA can differentiate these three factors in an AOM ear. Here we report wideband EA measurements in the AOM model of chinchilla at three experimental stages: unopened, pressure released, and effusion removed. These correspond to the combined and individual effects of the three factors on sound energy transmission. AOM was produced by transbullar injection of Haemophilus influenzae in two treatment groups: 4 days (4D) and 8 days (8D) post inoculation. These time points represent the relatively early and later phase of AOM. In each group of chinchillas, EA at 250-8000 Hz was measured using a wideband tympanometer at three experimental stages. Results show that the effects of MEP, MEE, and tissue structural changes over the frequency range varied with the disease time course. MEP was the primary contributor to reduction of EA in 4D AOM ears and had a smaller effect in 8D ears. MEE reduced the EA at 6-8 kHz in 4D ears and 2-8 kHz in 8D ears and was responsible for the EA peak in both 4D and 8D ears. The residual EA loss due to structural changes was observed over the frequency range in 8D ears and only at high frequencies in 4D ears. The EA measurements were also compared with the published TM mobility loss in chinchilla AOM ears.

Panel 1: Epidemiology and Diagnosis

Objective

To create a literature review between 2011 and June 1, 2015, on advances in otitis media (OM) epidemiology and diagnosis (including relevant audiology studies).

Data Sources

Electronic search engines (PubMed, EMBASE, and Cochrane Library) with a predefined search strategy.

Review Methods

Articles with appropriate epidemiologic methodology for OM, including acute mastoiditis and eustachian tube dysfunction. Items included OM worldwide and in high-risk populations, OM-related hearing loss, news in OM diagnostics, prenatal risk factors and comorbidities, postnatal risk factors, genetics, microbiological epidemiology, guidelines, and quality of life.

Conclusions

Diagnostic evidence and genetic studies are increasing; guidelines are introduced worldwide; and there is evidence of benefit of pneumococcal conjugate vaccines. New risk factors and comordities are identified in the study period, and quality of life is affected in children and their families.

Implications for Practice

Chronic suppurative OM occurs worldwide and contributes to lifelong hearing loss. Uniform definitions are still lacking and should be provided. An association between HIV and chronic suppurative OM has been found. Tympanometry is recommended for diagnosis, with or without pneumatic otoscopy. Video otoscopy, algorithms, and validated questionnaires may assist clinicians. Childhood obesity is associated with OM. Heritability accounts for 20% to 50% of OM diagnoses. OM-prone children seem to produce weaker immunologic responses to pneumococcal conjugate vaccines. Clinicians tend to individualize treatment without adhering to guidelines.

Otitis media

Otitis media (OM) or middle ear inflammation is a spectrum of diseases, including acute otitis media (AOM), otitis media with effusion (OME; 'glue ear') and chronic suppurative otitis media (CSOM). OM is among the most common diseases in young children worldwide. Although OM may resolve spontaneously without complications, it can be associated with hearing loss and life-long sequelae. In developing countries, CSOM is a leading cause of hearing loss. OM can be of bacterial or viral origin; during 'colds', viruses can ascend through the Eustachian tube to the middle ear and pave the way for bacterial otopathogens that reside in the nasopharynx. Diagnosis depends on typical signs and symptoms, such as acute ear pain and bulging of the tympanic membrane (eardrum) for AOM and hearing loss for OME; diagnostic modalities include (pneumatic) otoscopy, tympanometry and audiometry. Symptomatic management of ear pain and fever is the mainstay of AOM treatment, reserving antibiotics for children with severe, persistent or recurrent infections. Management of OME largely consists of watchful waiting, with ventilation (tympanostomy) tubes primarily for children with chronic effusions and hearing loss, developmental delays or learning difficulties. The role of hearing aids to alleviate symptoms of hearing loss in the management of OME needs further study. Insertion of ventilation tubes and adenoidectomy are common operations for recurrent AOM to prevent recurrences, but their effectiveness is still debated. Despite reports of a decline in the incidence of OM over the past decade, attributed to the implementation of clinical guidelines that promote accurate diagnosis and judicious use of antibiotics and to pneumococcal conjugate vaccination, OM continues to be a leading cause for medical consultation, antibiotic prescription and surgery in high-income countries.

Evidence-Based Systematic Review: Effects of Speech-Language Pathology Treatment for Individuals With Paradoxical Vocal Fold Motion

PURPOSE

In this article, our goal was to determine the state of the evidence and the effect of speech-language pathology (SLP) treatment for individuals with paradoxical vocal fold motion (PVFM).

METHOD

The American Speech-Language-Hearing Association's National Center for Evidence-Based Practice in Communication Disorders searched 22 electronic databases using key words related to PVFM, speech or voice treatment, and behavioral intervention for articles published through July 2013. Identified articles were systematically evaluated to assess the quality of the evidence using a modification of the American Speech-Language-Hearing Association's critical appraisal scheme.

RESULTS

Sixty-five articles met the search criteria. Only 2 out of the 65 articles were judged to contain adequate evidence to evaluate the effect of SLP treatment for PVFM. All 65 articles exemplify the state of the evidence for SLP treatment for PVFM.

CONCLUSION

The state of the evidence for the use of SLP treatment is in its infancy, with a majority of articles in the exploratory stage of research. Consequently, few clinical implications can be drawn at this time. SLP treatment for PVFM is promising; however, there is clearly a pressing need for systematic experimental studies that involve a control group to further the evidence base.

An Evidence-Based Systematic Review on the Diagnostic Accuracy of Hearing Screening Instruments for Preschool- and School-Age Children

PURPOSE

The purpose of this article is to conduct an evidence-based systematic review on the accuracy of pure-tone or otoacoustic emission (OAE) screening for identifying hearing loss in preschool- and school-age children.

METHOD

A systematic search of the literature published between 1975 and 2013 was conducted. Articles meeting the selection criteria were critically appraised for quality. Selection criteria required that behavioral thresholds be measured in children failing the screen and in at least a subset of children passing the screen. Sensitivity and specificity were used to calculate positive and negative likelihood ratios that could be compared between instruments.

RESULTS

Eighteen studies were included in the final analysis. There was considerable variability among studies on stimulus levels, response criteria, and definition of hearing loss. Approximately half of positive and negative likelihood ratio pairs for OAEs (52%) and pure-tone screening (45%) were considered suggestive or informative for identifying hearing loss.

CONCLUSIONS

Both pure-tone and OAE screening can identify hearing loss in preschool- and school-age children. Studies that compared both tools in the same population concluded that pure-tone screening had higher sensitivity than OAE screening and thus was considered the preferred tool. Future research should incorporate standard stimulus levels, response criteria, and definitions of hearing loss.